OAR 410-120-2000: HRSN Services Delivery

The purpose of this rule is to establish the processes, standards, and obligations required to be followed or met in administering and delivering Health Related Social Needs (HRSN) Services. (1) HRSN Services General Requirements; Overview of Administration and Delivery of HRSN Services. HRSN Services (defined in OAR 410-120-0000) are similar to Covered Services, but approval for receiving HRSN Services is not subject to the Medically Necessary and Appropriate standard required for Covered Services. Instead, in order for a Member to receive HRSN Services, the HRSN Service must be determined to be Clinically Appropriate (defined in OAR 410-120-0000). (2) HRSN Services are included in OHP Plus benefit package and are paid for on an encounter basis. (3) MCEs and HRSN Service Providers shall be compensated for the provision of HRSN Services in accordance with the HRSN Services Fee Schedule. The state must review the HRSN Fee Schedule at least once (1) every calendar year to determine whether changes need to be made as determined by the Authority in its sole discretion. Subject to the Authority’s reasonable discretion and applicable law, MCEs and HRSN Service Providers shall be compensated for HRSN Services on an encounter basis or incorporated into capitation rates. (4) MCEs and, as applicable, the Authority must provide Members with the same notices required to be provided for all other Covered Services, including, without limitation, Service Authorizations in accordance with 42 CFR 435.917, OAR 410-141-3835, and OAR 410-120-2020, and notices of Adverse Benefit Determination (ABD). (a) MCEs, and as applicable, the Authority shall notify all Members of the availability of HRSN Services, the process by which they may obtain an HRSN Eligibility Screening, and the standards for authorization of HRSN Services in their Member communications, in accordance with OAR 410-120-2020 and OAR 410-141-3585. (b) All notices must comply with accessibility requirements as required by 42 CFR 438.10, and OARs 410-141-3580 and 410-141-3585. (c) All HRSN service authorization notices must comply with OAR 410-120-2020. (d) All notices of Adverse Benefit Determinations (ABDs) must comply with 42 CFR §438.404, OAR 410-141-3885, 42 CFR §435.917 and OAR 410-120-1860 and include information that tells Members about their Grievance and Appeal rights under 42 CFR Part 438, Subpart F, OARs 410-141-3875 through 410-141-3915, 42 CFR 435.917, and OAR 410-120-1860. (5) HRSN Services administration and delivery consists of a number of tasks and activities which are required to be delivered by the HRSN Service Provider and MCE, or Authority, in accordance with the following administrative rules: (a) Identifying HRSN Eligible Members and conducting Outreach and Engagement of Members that complies with requirements detailed in OAR 410-120-2005 Tables 7 and 10; (b) Accepting requests for HRSN Services that comply with OAR 410-120-2010; (c) HRSN Eligibility Screening, Service Authorization, referring to an HRSN Service Provider, and ensuring delivery of an HRSN Service that complies with OAR 410-120-2005, OAR 410-120-2015, and OAR 410-120-2020; (d) Developing an HRSN Person-Centered Service Plan that complies with OAR 410-120-2025; and (e) Contracting with HRSN Service Providers that meet qualifications in compliance with OAR 410-120-2030. (f) Coordinating Member’s HRSN services in accordance with OAR 410-141-3860, OAR 410-141-3865, and OAR 410-141-3870 including during the following situations: (A) In the event a Member is disenrolled from their MCE and enrolled in a new MCE or with the Authority, and the Member has been screened and authorized for, but not yet received, an HRSN Service, or was receiving HRSN services at the time of their disenrollment and wishes to receive or continue to receive the authorized service, the new MCE, or as applicable, the Authority, must accept HRSN Eligibility Screening information used and provided by the predecessor MCE to conduct their own review as expeditiously as the Member’s circumstances require. In no event may the time for review exceed seven (7) calendar days following the receipt of the predecessor MCE’s information. (i) If it is determined by the new MCE or as applicable, the Authority, that the Member is still eligible for the HRSN service and wishes to receive it, the new MCE or as applicable, the Authority, must authorize and provide the HRSN service as expeditiously as the Member’s circumstances require, in accordance with OAR 410-120-2020. (ii) If it is determined by the new MCE or as applicable, the Authority, that the Member is no longer eligible for the HRSN service, the new MCE or as applicable, the Authority, must deny the HRSN service in accordance with OAR 410-120-2020. (B) In situations described in 5(f)(A) of this rule, to ensure continuity of care, the predecessor MCE or as applicable, the Authority, must provide the new MCE, or as applicable, the Authority, with the HRSN Eligibility Screening information used to support the HRSN service authorization and provision of HRSN service for the now-former Member. This information must be provided to the new MCE, or as applicable, the Authority, as expeditiously as the Member’s circumstances require, and no later than seven (7) calendar days following the Member’s disenrollment and receipt of the new MCE’s or Authority’s request for HRSN Eligibility Screening information. (C) In situations described in 5(f)(A), the new MCE or as applicable, the Authority, must avoid conducting unnecessary and redundant HRSN Eligibility Screenings and making requests to Members for documentation, if the predecessor MCE or the Authority is able to provide sufficient documentation to support the authorization and service provision of the HRSN service by the new MCE, or as applicable, the Authority. (6) HRSN Services delivered by the MCE, the Authority, or an HRSN Service Provider, shall be culturally and linguistically appropriate, responsive, and trauma-informed in accordance with National CLAS Standards and Trauma-Informed Care principles. (7) MCE and as applicable, the Authority, shall protect against conflicts of interest in the administration and delivery of HRSN Services. (a) An MCE and, as applicable, the Authority shall not deliver any HRSN Service that it has authorized unless the MCE can demonstrate it is the only willing and qualified organization that is capable of providing the HRSN Service to the HRSN Authorized Member within the service provision timelines described in OAR 410-120-2020. (b) The MCE and as applicable, the Authority must devise conflict of interest protections including separation of authorization and HRSN Service Provider functions within the MCE and as applicable, the Authority. (c) The conflict of interest protections devised by the MCE must be documented and is subject to the approval of the Authority, and must be retained and provided if requested for Authority audit or other review.